postoperative care and complications after thoracic...

Chapter 3

Postoperative Care and Complications After ThoracicSurgery

Anand Iyer and Sumit Yadav

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/55351

1. Introduction

Postoperative care of thoracic surgical patients is a very important part of patient recovery andcan be very challenging. Pulmonary complications are responsible for significant numbers ofdeaths and morbidity of patients undergoing thoracotomy. Thoracic surgery impairs postop‐erative respiratory function resulting in a relatively high risk of developing postoperativepulmonary complications. The incidence (19-59%) is much higher than following upper(16-17%) or lower abdominal surgery (0-5%). The overall incidence of complications followingthoracic surgery varies from 15% to 37.5%, primarily due to the type of pulmonary complica‐tions studied, the clinical criteria used in the definition and the type of surgery included. Theclinical and potential economic impact of these complications is marked, with significantlylonger hospital and high Dependency unit stay, frequency of ICU admission and number ofdeaths.

A centre can achieve excellent results by concentrating on the basics of postoperative care likepulmonary hygiene and physiotherapy, fluid and pain management and management ofpleural spaces. Risk factors for complications following thoracic surgery have been identifiedfrom numerous clinical studies using a variety of research designs and definitions. The mostfrequent risk factors include age, preoperative pulmonary function tests, cardiovascular comorbidity, smoking status and chronic obstructive pulmonary disease (COPD). [1]- [4] In thecurrent era there has to be more emphasis on postoperative care due to the complexity ofreferrals with the thoracic units doing more patients with multiple risk factors for postoperative complications. This gets more challenging with cost containment.

High-risk patients can be optimised with preoperative and postoperative cardiopulmonaryrehabilitation to reduce their operative risk, frequency of complications and hospital stay andimprove postoperative outcomes including postoperative lung function. [5], [6] In addition,

© 2013 Iyer and Yadav; licensee InTech. This is an open access article distributed under the terms of theCreative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permitsunrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

preoperative pulmonary rehabilitation may improve preoperative exercise capacity and sooperability. [7], [8] The future development and adoption of innovative strategies is requiredto reduce the impact of post operative complications in an ageing co morbid population.

In this section will cover the routine care of a postoperative thoracic patient with specificemphasis on prevention and management of common complications.

2. Preoperative optimisation of specific risk factors

The outcome of surgical procedures is not measured only by clinical end points but also shorterstays and lower costs [9]. Patients’ discharge is delayed commonly due to inadequate painrelief, infection, arrhythmias, prolonged air leak and debility [9]. Many complications thatoccur from thoracic operations can be anticipated. An aggressive preoperative work upmitigates morbidity and shortens convalescence.

2.1. Smoking

Preoperative cessation of smoking prevents postoperative complications to a large extent.

Support groups, counselling and nicotine replacement therapy should be used [10]. Histori‐cally, 6 weeks of smoking cessation before surgery is recommended to avoid the copiousbronchorrhea that accompanies regeneration of the cilia that clear mucus between 2 and 4weeks after smoking cessation [11].there are few studies which challenge this challenge thisnotion of timing of smoking cessation. Even 3-5 days of stopping could improve clearance anddecrease of secretions. Vaporciyan el al showed that patients who quit smoking 4 weeks ormore before surgery had a lower incidence of pulmonary complications than patients whocontinued to smoke or quit fewer than 4 weeks before pneumonectomy [12]. However, Barreraand co-workers found no difference in the incidence of pulmonary complications betweenpatients who were still smoking at the time of surgery and those who had quit fewer than 2months before thoracotomy for lung resection [13]. In many centres including ours therecommendation is to stop smoking at any time and provide support services to help out withthe same.

2.2. Preoperative education and physiotherapy

Preoperative physiotherapy and education is done in many centres as part of work up forthoracotomy. Physiotherapists and thoracic ward medical and other staff perform a variety ofcare for patients undergoing surgery both pre and post operatively. All these are done toprevent postoperative complications like atelectasis, pneumonia, effusions and empyema.Various manoeuvres include education, deep breathing and coughing manoeuvres, chestphysiotherapy and early mobilization education post sugery [14]. According to few studiesthis has led to an improvement in the prevention of atelectasis, collapse and consolidation.Many other interventions like incentive spirometry and respiratory muscle strengthening have

Principles and Practice of Cardiothoracic Surgery58

been shown to reduce the incidence of these complications. During the work up assessmentof the pulmonary functions are done and bronchodilators optimised.

In the education session instructions may be given for deep breathing and splinted coughingexercises, prophylaxis exercises for deep vein thrombosis, and shoulder exercises [15]. Therestudies which question the benefit of preoperative education and physiotherapy and fewstudies have shown them to be non-beneficial16 but we continue to follow preoperativeeducation as well as physiotherapy prior to thoracic surgery.

Patients are also investigated for cardiac ailments if there are symptoms, signs or significantcardiac history prior to performing elective thoracic surgery. Investigations may includeechocardiography, cardiac viability study or angiogram. Patients who are on antiplateletsshould have their medications withheld 7 days prior to surgery is possible. If patients are onwarfarin then it is stopped 3 days prior to surgery and are covered with heparin

Patients are given a single dose of antibiotics for elective cases and they are continued forinfected cased or restarted postoperatively if needed. If surgical intervention is elective, weadvocate a short period of preparation may be beneficial if directed at improving the patient'sphysical status and specifically at pulmonary preparation, conditioning exercises, andnutrition.

3. Operative factors

3.1. VATS vs. OPEN

Video assisted Thoracoscopic procedures are done with increasing frequency for manyindications. The incidence of postoperative complications is 9% after VATS and they includehaemorrhage, empyema, air leak, pneumonia and surgical emphysema [17] commonly butmost of the complications which happen in thoracotomy could potentially happen with videoassisted Thoracoscopic procedures.

Most importantly the incidence of postoperative pain is much less in VATS than openprocedures and they have shorter hospital stay. The proponents of VATS have published manyseries about the feasibility, lesser complication rate, reduced pain, early mobility and discharge[18], [19]. There are groups who did not find any statistical benefit in performing VATS andhave quoted a higher bleeding and intraoperative complication rate [20]. In our unit weperform VATS for all kinds of thoracic procedures if patients are suitable for it. VATS lobec‐tomy is a safe procedure, which reduces peri operative pain and improves postoperativephysical status. The results obtained with early stage lung cancer are excellent and may reflectinherent oncologic advantageous consequent upon reduced operative trauma. Detection ofearly stage lung cancer is potentially rewarding and will become a practical imperative ifsurvival results are to be improved. Thus the scope for VATS resection may increase signifi‐cantly. In our view VATS lobectomy is the procedure of choice for early stage lung cancer andmulticentre prospective randomised trials comparing this therapy against conventional openresection are overdue.

Postoperative Care and Complications After Thoracic Surgeryhttp://dx.doi.org/10.5772/55351

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3.2. Use of staplers and glues to reduce and seal air leaks

Various procedures like wedge resections, lobectomies, excision of bullae may cause pro‐longed air leaks especially if patients have COAD. Traditionally diathermy dissection andligation was used and later staplers were used for parenchymal resections. Although certainstudies pointed towards improved results with regards to air leaks using staplers [21] andreported that surgical morbidity due to air leaks decreased with this technique other studieshave not shown any particular reduction in duration of air leaks using staplers alone. [22]

The air leaks caused by the holes of the suture needles are of the same magnitude as that causedby the surface tension between the parallel staple lines when the lung inflates. Neverthelessstaplers are quicker to use and they have a big role in minimally invasive Thoracoscopicprocedures

Polyglycolic acid fabric, polydioxan ribbon, bovine pericardial strips, bovine collagen, andrecently, expanded polytetrafluoroethylene have been employed in an attempt to reinforce thestaple lines, especially for resections performed in emphysematous lungs [23]- [27]. Othertechniques like the electrothermal bipolar sealing have shown good results in lung parenchy‐mal surgery.

Air leaks are common after pulmonary resections. They can be inspiratory, expiratory,continuous and forced expiratory. Most of the leaks are expiratory or forced expiratory.Inspiratory leaks happen on positive pressure ventilation. If there is no pleural space then theyare managed by underwater seal. If there is a space negative suctions is applied to theunderwater seal. If the leak persists beyond a particular time frame then TALC or reopeningshould be considered.

4. Post operative care

4.1. Pain management

Pain management is of paramount importance post operatively as it is essential for patients tocomply for chest physiotherapy and ambulation and they will be unable to do so if they havesevere pain. There are various ways by which pain is managed. They include epidural catheterspreoperatively, paravertebral methods pre or intraoperatively or intravenous patient control‐led analgesia. On withdrawing these agents patients will need oral analgesics for duration oftime till they are pain free. These include paracetamol, NSAID and narcotic agents.

4.1.1. Epidural analgesia

The catheter is placed approximately with the midpoint of the dermatomal distribution of theskin incision. Epidural local anaesthetics increase segmental bioavailability of opioids in thecerebrospinal fluid and increase the binding of opioids to m receptors and the blocking of therelease of substance P in the substantia gelatinosa of the dorsal horn of the spinal cord [28].The thoracic segmental effects of local anaesthetic and opioid combinations is the only way to


minimize motor and sympathetic blockade maintain conscious level and cough reflex andreliably produce increased analgesia with movement and increased respiratory function afterthoracotomy [29]. Generally the most popular regimens are fentanyl or diamorphine combinedwith levobupivacaine [29]. The regimens can be administered as an infusion, patient controlledanalgesia or both.

Potential issues include failure, technical difficulty and hypotension. It can also reduce theeffectiveness of coughing, especially in patients who already have a low FEV1. It is not offeredwhen there is local or systemic sepsis.

Paravertebral block is an effective modality to provide pain relief. It can be done by theanaesthesiologist before the start of surgery or by the surgeon before closure. It offers severaltechnical and clinical advantages and is indicated for anaesthesia and analgesia when theafferent pain input is predominantly unilateral from the chest and/or abdomen. We preferplacing the catheter under direct vision during thoracic surgery and give pain relief as acontinuous infusion. The chest drain loss of local anaesthetic is four times lower than that ofinterapleural block [30].

4.1.2 Systemic analgesics

Opioids remain the mainstay of postoperative analgesia and have demonstrated their efficacyin the management of severe pain. The side effects include nausea, vomiting, ileus, biliaryspasms and respiratory depression, Opioids can be administered IM, subcutaneously, or IV.

A very efficient method of delivery of opioids is via PCA (Patient Controlled Analgesia)devices. Numerous studies have demonstrated the safety and opioid-sparing effect of PCA.After thoracic surgery PCA is often combined with other modalities to offer adequate painrelief.

4.1.3. Intrapleural

Intrapleural local anaesthetics produce a multi-level intercostal block. However, the analgesiais extremely dependent on patient position, infusion volume, and the type of surgery. Withthe drains insitu most of the anaesthetic is drained out and hence the efficacy of the procedureis less. In spite of occasional successes most clinicians have not found the reliability ofintrapleural techniques adequate to justify their use on a routine basis. [31]

4.1.4. Other techniques

Cryoanalgesia is the application of a -600ºC probe to the exposed intercostal nerves intra-operatively produces an intercostal block that can persist for up to six months. This can bemoderately efficient to decrease post-operative pain, but is associated with an incidence ofchronic neuralgia that has lead many centres to abandon the technique [32]. Transcutaneouselectrical nerve stimulation (TENS) may be useful in mild to moderate pain but is ineffectivewhen pain is severe. [33]


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4.2. Management of fluid electrolytes

Patients are managed generally in a high dependency unit post surgery or the wards if it is adedicated thoracic unit. Post thoracic surgery especially in resections intravenous fluids aregiven in reduced amounts to prevent pulmonary insufficiency. Care is taken not to overhydratethe patient and oral feeding in encouraged as soon as possible. Intravenous fluids should beused judiciously and a conservative strategy of administration of maintenance fluids isrecommended at 1–2 ml/kg/h in the intra- and post-operative periods and that a positive fluidbalance of 1.5 l should not be exceeded, to mitigate the risk of multifactorial post operativeacute lung injury/ARDS. Caution should be exercised with regard to silent hypovolaemia,impaired oxygen delivery and acute kidney injury. A high index of suspicion for pulmonaryinsufficiency should be adopted if there is volume overload. If a patient develops signs of hypoperfusion after these thresholds are exceeded, inotropic/vasopressor support should beconsidered. [34]

4.3. Intercostal catheter

Intercostal catheter is watched for drainage and air leak. If the postoperative chest X-ray showsexpanded lung fields the no suction is applied even if there is bubbling. If there is airspace thesuction is applied. It is preferable to use a balanced drainage system in all patients. In pneu‐monectomy patients no suction is applied after surgery and the balanced drainage system isfilled with 1cm of liquid unlike routine thoracic cases where it is filled with 2 cm of fluid. Inpneumonectomy patients the drains are removed the next day and in lobectomy patients assoon as possible. Suction is also applied in cases of pleurodesis with talc so that the visceraland parietal pleurae are approximated. If the drains have to stay due to persistent minimalbubbling and if the parenchyma is expanded without any suction a Heimlich valve containeris attached for earlier complete ambulation or discharge.

4.4. Physiotherapy and early mobilisation.

Postoperative insufficiency occurs because of infection, inability to clear secretions or oedemaaround day 2 or 3, to prevent these from happening attention should be given to physiother‐apy, bronchodilators, restriction of intravenous fluids and tracheal toilet. Chest physiotherapyincludes deep breathing and coughing exercises and incentive spirometry. Pulmonaryinsufficiency is more common in patients have low FEV1. If there is inability to do so thenendotracheal suctioning or mini tracheostomy should be used for clearing secretions. Diureticsare used if necessary and antibiotics are started if clinically indicated without waiting forradiological deterioration.

Early postoperative ambulation and physiotherapy reduces complications like atelectasis,pneumonia, empyema and DVT.

Aspiration should be prevented postoperatively as it can result in multiorgan dysfunction andsepsis. Patients should be allowed to eat only when they are fully alert and sitting up. If thereis a tendency to aspirate patients are kept nil by mouth and nasogastric feeding initiated asrequired. If there is damage to the vocal cords then a speech pathology is sought for and


patients are initially kept on nasogastric feeds and based on recovery are put on graded dietbeginning from thickened fluids.

4.5. Deep Venous thrombosis prophylaxis

The prophylaxis should start when the patients are admitted in the hospital. Everyone shouldbe given a prophylactic dose of heparin subcutaneously if not contraindicated at a dose 5000IU twice daily and this is continued in the postoperative period till discharge. All patientsshould have stockings and the high-risk patients should be on compression stockings. If thereare signs of DVT then a Doppler in arranged and patients put in treatment dose of heparininfusion and an IVC filter put in if necessary.

5. Complications

5.1. Postoperative haemorrhage

Immediate postoperative bleeding can be caused due to surgical bleeding or coagulopathy,surgical bleeding being more common. A set of standard coagulation tests are performed andcoagulopathy is corrected accordingly. Depending on the coagulation profile factors like FFP,Platelets, cryoprecipitate or factor 7 is given if the patient is bleeding due to profound coagul‐opathy.The threshold for taking back a patient for re-exploration should be low, as a surgicalcause of bleeding should be ruled out. Bleeding after thoracic surgery is rare. It occurs in lessthan 2% of video assisted Thoracoscopic procedures (VATS) and around 01% to 3% of openprocedures. [35]- [38] Generally postoperative bleeding results from technical complications,but certain co morbidities may predispose a patient to bleeding. A chest tube output of 1000ml in 1 hour necessitates an immediate return to the operating room with concurrent correctionof coagulopathy. Serial drainage exceeding 200 ml per hour for 2 to 4 hours after correction ofa coagulopathy also indicates surgical bleeding and dictates re-exploration. If the patient ishemodynamic ally stable but the chest output is high, checking the haematocrit on the chesttube drainage can be helpful in distinguishing active bleeding from a lymphatic leak. If apatient in the immediate postoperative period is hemodynamically unstable but the chest tubeoutput does not suggest active haemorrhage, a chest radiograph may show radiopacity of theoperative side with thrombosed chest tubes. [40]

Medications like aspirin, other antiplatelet agents’ warfarin could cause increased bleed‐ing tendencies. Several herbs like garlic, ginseng etc. effect a prolonged bleeding time,which can result in peri operative haemorrhage. [39] The effect of herbal medications inthoracic surgery specifically is lacking, but discontinuing herbs 2 weeks before a lung re‐section is recommended. [40]

Recommendation for perioperative antiplatelet the current recommendations aim at providingthe best option for patients. There are issues regarding continuing or discontinuing thesemedications. These recommendations are mainly form observational data. [41], [42], [43]


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In the current era Aspirin is a lifelong therapy and it is not necessary to stop it for surgerywhen there are specific indications like prevention after stroke, acute coronary syndrome, MI,or coronary revascularization, regardless of the time since the event that led to the recom‐mendation of aspirin. [44]

Dual antiplatelet therapy is recommended during the two weeks after simple dilatation, sixweeks after bare-metal stents, and at least 12 months after drug-eluting stents. [41], [42], [43]Elective operations should be postponed beyond these delays but most of the thoracicprocedures have to be done as soon as possible as a bulk of cases are due to malignancy henceunless the hemorrhagic risk is excessive, dual antiplatelet therapy should not be interruptedbefore surgery.

Even if clopidogrel treatment must be interrupted in high-risk surgical situations, aspirin mustbe continued without interruption.41,42,43 Heparin has no antiplatelet activity and thereforeis not an adequate substitution for aspirin or clopidogrel treatment because stent thrombosisis a platelet-mediated phenomenon. [42] Although not proven by any randomised controlledtrials bridging therapy with a short-acting platelet glycoprotein IIb/IIIa inhibitor like tirofibanis a possible substitution for clopidogrel while aspirin is being maintained. [46] After theoperation, antiplatelet therapy is resumed within the first 12 to 24 hours; clopidogrel therapyis reinitiated with a 300-mg loading dose, which reduces the time to achieve maximal plateletinhibition to four to six hours and decreases the risk of hyporesponsiveness from competitionof other drugs with hepatic cytochromes.

Ticagrelor is used more often these days and should be stopped 36 to 48 hours prior to aplanned procedure. It is reversible P2Y12 adenosine disphosphate receptor binder with shorterduration of action unlike clopidogrel which is irreversibly binds to it. The perioperativemanagement for it is similar to the clopidogrel.

Warfarin should be discontinued 3 days preoperatively, the INR checked. It should besubstituted with heparin and APTT checked.

Conversion to an open thoracotomy for control of bleeding is done in case of bleeding due toVATS. Intraoperative bleeding can be massive from injury to the pulmonary artery or vein.Proximal control of the pulmonary artery before dissection of its branches is a safe preventivemeasure in open lobectomies. Rarely vascular stapler on a pulmonary vessel can causebleeding and so can its used in the parenchyma. Suturing of the lung is done to controlbleeding. Bleeding can also happen from peribronchial tissue, parenchyma, adhesions,intercostal vessels, and muscles.

In some patients, postoperative bleeding develops that is not hemodynamically significantenough to indicate re-exploration but results in a residual clotted hemothorax. As is true for aposttraumatic clotted hemothorax, treatment options include VATS or open exploration andevacuation of the hematoma to prevent development of a trapped lung, respiratory compro‐mise, and empyema.


5.2. Cardiac complications

Arrhythmia, more particularly atrial fibrillation (AF), is by far the most common cardiaccomplication after thoracic surgery, with an incidence ranging from 10% to 20% after lobec‐tomy and as much as 40% after pneumonectomy [46]- [47]

Risk factors for tachyarrhythmias include [48], patient related (pre-existing cardiovasculardisease, postural change, limited pulmonary reserve), surgery related (extensive procedure,intrapericardial pneumonectomy, extra pleural pneumonectomy, anaesthetic agents, majorbleeding), treatment related (previous thoracic irradiation) or older age [47], [49]. The mostcommon arrhythmia encountered is supraventricular tachycardia.

If patients have atrial fibrillation with haemodynamic compromise then electrical cardiover‐sion should be carries out immediately. If patients have sympromatic AF chemical cardiover‐sion should be attempted first followed by electrical cardioversion if necessary. New-onsetpostoperative AF is often transient and self-limiting and it is generally accepted that ratecomtrolling agents be given first. Rate control resolves AF in most cases in thoracic surgery.AF generally resolves within 1 day of hospital discharge with rate control alone. [50]

A selective Beta 1-blocking agent is recommended as the initial drug for rate control in theabsence of moderate-severe chronic obstructive pulmonary disease or active bronchospasmsand Diltiazem should be the first agent used in the presence of moderate-severe chronicobstructive pulmonary disease or active bronchospasm. [51]

Digoxin as a single agent should not be used for rate control, although it may be effective incombination with a beta1-blocker or diltiazem. Beta blockers are considered better thancalcium channel blockers and digoxin for treating AF in thoracic surgery. The only concern isCOPD where it may cause bronchospasms specific beta 1 blockers such as metoprolol areconsidered safer in this regard. [52]

When chemical cardioversion is employed in the setting of continuous or recurrent paroxysmalpostoperative AF, the most reasonable initial drugs are intravenous followed by oral amio‐darone or oral flecainide. [51]

Amiodarone is not given if the patient has severe lung disease or if the patient as under‐gone pneumonectomy The incidence of ARDS was 11% in the patients treated with amio‐darone and 1.8% in the nonamiodarone group [53]. Flecainide is not given if there isorganic cardiac disease. Other drugs include disopyramide, ibutilide, procainamide, prop‐afenone, quinidine, and sotalol. Patients who received flecainide had an approximatelydoubled rate of mortality or cardiac arrest, likely due to a proarrhythmic effect on theventricle possibly due to structural heart disease. Side effect of amiodarone relevant tothoracic surgery is its pulmonary toxicity [51].

Both amiodarone and flecainide are highly effective and relatively safe drugs, but the specificcontraindications to their use must be kept in mind antiarrhythmic therapy is given usuallyfrom 1 to 6 weeks. The only study that has evaluated optimal length of therapy with antiar‐rhythmic drugs, once initiated, for postoperative AF (after coronary artery bypass graft


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surgery) found that there was no difference in the rate of recurrent AF whether the treatmentwas continued for 1, 3, or 6 weeks after discharge. [54]

Anticoagulation Therapy For patients with two or more risk factors for stroke (age >75 years,hypertension, impaired left ventricular function, prior stroke or transient ischemic attack) whohave postoperative AF that recurs or persists for more than 48 hours, anticoagulation therapyis reasonable if not otherwise contraindicated. [51]

For patients with fewer than two risk factors for stroke and patients considered not suitablefor warfarin who have postoperative AF that recurs or persists for more than 48 hours, aspirin,325 mg daily is recommended. [51]

Oral metoprolol initiated preoperatively and continued postoperatively decreased theincidence of atrial fibrillation from 40% to 6.7% (p <0.05). [55] In another trial, administrationof magnesium sulphate starting the day of operative resection also resulted in a decrease inthe incidence of atrial fibrillation from 26.7% to 10.7. [56]

5.3. Ischemia

In a large series the incidence of ischemic electrocardiographic changes was 3.8% and myo‐cardial infarction in 1.2%. According to this study hypotension and abnormal exercise testingwere the strongest predictors for ischemic events. [57]

Patients are monitored invasively, base line medication was continued, and peri operativefluid administration was minimalized. We recommend continuous monitoring for at least 2days in high-risk patient.

The American College of Cardiology and the American Heart Association guidelines [58] forperi operative cardiovascular evaluation for no cardiac surgery remain the best availablemethod for risk assessment in noncardiac thoracic surgery. Thoracic surgery is categorized asa high-risk surgical procedure in this matter. Coronary angiography is advocated in case ofmajor clinical predictors such as unstable angina, decompensated heart failure, significantarrhythmias, or severe valvular disease. In cases of intermediate or minor clinical predictorsthe decision whether to perform an angiography is based on non-invasive testing [59].

As adenosine and dipyridamole should be avoided in patients with clinical bronchospasms,dobutamine stress echocardiography is the evaluation of choice for patients with cardiacischemia referred for thoracic surgery [60]. In general the indications for coronary angiographyare similar to those in the nonoperative setting. No prospective randomized data exists on therole of prophylactic coronary bypass surgery. Whether percutaneous coronary intervention issuperior to bypass surgery is uncertain, but in cases of angioplasty with stenting it is probablysafer to postpone surgery for 2 to 4 weeks. In conclusion, the preoperative cardiac assessmentof thoracic surgery patients is of great importance, although prospectively controlled data forthis type of surgery are lacking. [59]


5.4. Right-to-left shunt

It is estimated that 20% of the general population may have a persistently patent foramenovale (PFO). With the increased right-sided pressures associated with pulmonary resec‐tion, these patients can develop a right-to-left shunt with refractory hypoxia in the post‐operative period. This shunting increases most dramatically after a rightpneumonectomy. In some patients, symptoms may not present until after 1 to 5 months,particularly after a right pneumonectomy. [61] Patients often present with dyspnoea (pla‐typnea) and hypoxia (orthodexia) in the upright position, which resolves upon recum‐bence. This is because of nediastinal shift, which modifies the relationship between theright and left atrium and distorts the foramen ovale. Cardiac rotation and compression ofthe right atrium by pleural fluid causes preferential flow of the inferior caval vein intothe left atrium. Hemodynamic factors may also have a role, such as reversal of the intera‐trial pressure gradient. A decrease in right ventricular compliance and the hydrostaticpressures in the left lateral decubitus or orthostatic positions increase the shunt. Lastly,factors such as pulmonary emboli, right ventricular infarction, increased intrathoracicpressure, chronic obstructive pulmonary disease, and positive pressure ventilation maydrive shunt physiology. [62] The aetiology of this complication is unclear.

The diagnosis is made with arterial blood gas analysis, nuclear lung perfusion scanning,echocardiography, MRI, and cardiac catheterization or a combination thereof. Standardtreatment is surgical repair, although several cases of successful intravascular occlusion of theseptal defect have been performed.

Other causes of dyspnoea must be evaluated, including but not limited to pulmonary embo‐lism, airway narrowing, and post resection pulmonary oedema.

5.5. Cardiac herniation

Cardiac herniation is a rare complication and happens in the early postoperative period.Cardiovascular collapse is the presenting feature Jugular pulse is elevated and there can becyanosis in the drainage area of superior venacava. Ventricular fibrillation may occur [63].Treatment is emergency thoracotomy with reposition of the herniated heart into the pericardialsac and repairing the defect of the pericardium [64]. Most documented cases of cardiacherniation have occurred through surgically created defects as a result of intrapericardialpneumonectomy or lobectomy with partial pericardectomy [65]. Combination of a suddensuperior vena cava syndrome and heart sounds in the right side of the chest should alert thephysician to the possibility of cardiac herniation. Surgical defects of the pericardium as a resultof right intrapericardial pneumonectomy should be closed. This can be accomplished eitherby suturing the cut edges of the pericardium to the epicardium or by patching the defect withbovine pericardial patch, PTFE patch or parietal pleura. In cases of left pneumonectomy, itmay be sufficient to enlarge the pericardial defect in order to prevent strangulation, shouldherniation occur [66].


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5.6. Heart failure

Few studies have addressed the problem of postoperative right ventricular dysfunction, whichis because of changes in right ventricular afterload and contractility [67]- [71]. Although rightventricular end-diastolic volume remains stable in the early postoperative hours, significantincreases may be observed on the first and second postoperative days. Although many authors[69]- [71] claim that afterload alteration is the major determinant of RV dysfunction. Pulmonaryartery pressure and pulmonary vascular resistance only rose modestly in a study [66],suggesting that the rise in afterload is not the only causing factor. Another argument favouringafterload augmentation as the cause of RV dysfunction is the fact that postoperative pulmonaryartery pressure, pulmonary vascular resistance, and central venous pressure only changesignificantly during exercise [70]. Changes in RV function are able to compensate for theincreased RV end-diastolic volume at rest, but not during exercise, with a resultant increasein pulmonary artery pressure and pulmonary vascular resistance. [59] One study used seriallyperformed transthoracic echocardiography to assess the effects of pulmonary resection [71].Only pneumonectomy patients had mild postoperative pulmonary hypertension withoutsignificant RV systolic dysfunction. Pulmonary embolism and cardiac herniation are raremechanisms that may cause RV dysfunction.

Left heart failure is generally a consequence of impaired right heart function, either bydecreasing left ventricular preload or by shifting the intraventricular septum resulting in adecreased left ventricular volume. Other causes of left ventricular dysfunction are acutemyocardial infarction, pre-existing valvular disorders or cardiac herniation. [59]

5.7. Pulmonary oedema

Respiratory complications occur in 5-14% of patients [72]- [74]. The risk factors include age ofthe patient, extent of resection, preoperative lung function and other co morbidities.

However, a number of case studies have described what appears to be a specific syndrome ofpost pulmonary resection lung injury, which has been called post‐pneumonectomy pulmonaryedema (PPO). [75], [76], [77] The syndrome consisted of the onset of severe respiratory failure,within 48 h of operation, associated with diffuse radiographic changes on plain chest filmsconsistent with pulmonary oedema. However, central pressure measurements showed noevidence of left ventricular failure or cardiogenic pulmonary oedema. Its incidence is approx‐imately 2.5% to 4% [78]- [83].

The mechanisms of injury are that ischaemia–reperfusion injury and [84] reactive oxygenspecies. [85] Pulmonary capillary stress failure occurs when the pulmonary microvascular bedis subjected to increased pressure and could produce capillary injury. [86]

Following are the recommendations and statements concerning fluid administration: (1) thereis no "third space" in the thorax, (2) total positive fluid balance in the first 24 hours should notexceed 20 mL/kg, (3) a urinary output greater than 0.5 mL/kg/h is unnecessary, (4) the use ofinvasive monitoring techniques is advisable if increased tissue perfusion is necessary postop‐eratively, (5) factors that contribute to increased pulmonary venous pressures should beminimized postoperatively, (6) hyperinflation of the residual lung should be avoided, (7)


regular chest roentgenograms should be obtained postoperatively, (8) prolonged periods withthe residual lung in the dependent position should be avoided, and (9) prophylactic digitali‐zation has not been shown to reduce the incidence of post resection supraventricular arrhyth‐mias or of postpneumonectomy pulmonary edema. [59]

Therapy [59] consists of administration of diuretics, restriction of fluid, nutritional support,and maintenance of adequate oxygenation, even with mechanical ventilation if necessary.Despite aggressive treatment, the clinical outcome is poor with mortality exceeding 50%. Nitricoxide ventilation and extracorporeal membrane oxygenation were tried as possible therapies.In particular the use of inhaled nitric oxide, in doses of 10 to 20 ppm, was able to lower mortalityrates to 30% in a small series of patients. In the same report early intubation (at first signs ofARDS), aspiration, bronchoscopy, and postural changes are also advocated.

Pulmonary hypertension is a major concern for patients undergoing general thoracic surgeryand often contraindicates pulmonary resection. Multiple aetiologies exist, such as cardiomy‐opathy or intrinsic cardiac valvular disease, as well as destructive pulmonary parenchymalprocesses resulting in cor pulmonale. The presence of pulmonary hypertension puts patientsat increased risk for anaesthesia and surgical morbidity.

5.8. Postpneumonectomy syndrome

Postpneumonectomy syndrome refers to bronchial compression occurring as a result ofmassive mediastinal shift following pneumonectomy [87]- [89]. Incidence is approximatelyone in 640 cases [90]. This syndrome is much more common after right pneumonectomy: themediastinum undergoes counterclockwise rotation as it shifts toward the pneumonectomyspace [87], [88], [90], [91], [92]. This results in stretching, distortion, and compression of the leftmain bronchus between the pulmonary artery anteriorly and the aorta and vertebral columnposteriorly. The syndrome has also been described after left pneumonectomy, both in patientswith and without an aberrant right aortic arch [92], [94], [95], [96], [99]

Risk factors include young age and female sex [88], [97], [98]. These patients have more elasticmediastinal tissues (thus prone to shifting) and a softer, more compliant airway (thus subjectto compression). [77] Patients typically present with exertional dyspnoea, stridor, andrecurrent pulmonary infection] within one year of pneumonectomy. The onset is usuallygradual, but acute obstruction may ensue in children. [99]

Airway stenting has been used in the treatment of inoperable patients and as a bridge tosurgery in cases of acute obstruction [95], [98]. Definitive treatment involves surgical reposi‐tioning of the mediastinum in the midline. The mediastinum is then maintained in position bya saline-filled silicone prosthesis which is inserted into the pneumonectomy space. [99]

5.9. Lobar torsion and gangrene

Lobar torsion represents a rotation of the bronchovascular pedicle with resultant airwayobstruction and vascular compromise. This disorder has been described in 3 different circum‐stances: as a complication of thoracic surgery, after blunt trauma, and spontaneously [100]


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The overall incidence of lung torsion has been reported as 0.089%–0.2%, and is equally rareafter thoracic surgery. [100], [101]. The pathophysiological mechanisms of torsion develop‐ment were previously postulated as an airless lobe, incision of the inferior pulmonary ligament,pleural effusion, a long slim lobar pedicle, and lack of pleural adhesions. [100]

Patient’s condition manifests as high fever, severe chest pain, massive haemoptysis, bron‐chorrhea, and sepsis, seen radiographically as abrupt consolidation and abnormal location ofthe collapsed lung. Only meticulous observations of both clinical and radiological manifesta‐tions, although uncharacteristic, can provide an indication of torsion development. [102].Thereafter, bronchoscopy, contrast chest computed tomography, or angiography can bediagnostic in finding the distorted or occluded bronchi or tapered pulmonary artery. [100],[102]. Subsequent manoeuvres, such as contrast computed tomography, would have beendiagnostic and prompted reoperation. Intrathoracic bleeding was suspected considering thehistory of extensive mediastinal adhesions, voluminous drainage, and blood loss. Thedistinguishing features were: the chest opacity appeared hypertensive, and the resultant hugetension markedly shifted the mediastinum; the serous fluid drainage, albeit a large amount,was inconsistent with the severity of the anaemia; and radiographically, there was a convexpulmonary margin around the chest tube. Wagner and Nesbitt stated that lobar torsion afterright upper lobe resections accounted for 70% of the cases in the literature, whereas 15%followed resection of the left upper lobe. Torsion could happen in any lobe [103]

Options for surgical intervention include simple detorsion or resection of the involvedpulmonary segments. Detorsion alone is advocated only in patients who undergo re-inter‐vention within a few hours of the primary procedure; while in the majority of patients,pulmonary resection is mandatory due to pulmonary gangrene. Embolisms to other vitalorgans are the main complications after surgery, which should therefore be carefully moni‐tored. [102]

It seems reasonable to staple or suture the middle lobe to the lower lobe after a right upperlobectomy if the oblique fissure is complete to prevent middle lobe torsion. Postoperatively,the possibility of a lobar torsion after lobectomy should be considered when an infiltrate orcomplete atelectasis persists or worsens; bronchoscopic intervention should be performedpromptly.

5.10. Cardiac tamponade

Pericardial tamponade, though rare after open lobectomy, should be considered along withother complications when a patient repeatedly develops hypotension with therapies thatcauses venodilation. A rising CVP and its equalization with pulmonary artery diastolicpressure indicate cardiac tamponade. Symptoms include those related to cardiac tamponade:low cardiac output and Beck's triad (hypotension, muffled heart sounds, and increased centralvenous pressure). Diagnosis of this complication again requires a high index of suspicion.Echocardiography is the diagnostic study of choice to visualize impaired filling of the rightventricle because of increased pericardial pressure from the pericardial effusion.


Treatment include an urgent pericardiocentesis as a temporizing measure followed byreopening of the thoracotomy or a formal median sternotomy, which allows full inspection ofthe interior of the pericardium and provides adequate access for definite management of thecause. Minor injuries during retraction and dissection can produce life-threatening conditionslike pericardial tamponade. Episodes of unexplained hypotension suggest a cardiac aetiology;a high index of suspicion and urgent surgical intervention can prevent adverse outcome.

5.11. Chylothorax

The thoracic duct can be injured during any thoracic procedure. Pleuro-pulmonary proce‐dures, esophageal resection, intrapericardial and mediastinal procedures, and even lessinvasive procedures like subclavian puncture may lead to thoracic duct injury and subsequentchylothorax [104]- [108]. The incidence of chylothorax after pulmonary resection is between0.7% and 2%. [109]- [110] This complication typically occurs at the time of resection. Aetiologiesin thoracic surgery include aggressive mediastinal lymph node dissection with incompleteligation of lymphatic channels or direct injury to the thoracic duct either during extra pleuralpneumonectomy or division of the pulmonary ligament. There will be loss of calories, fluids,and proteins cause nutritional deficiency, dehydration, and immunologic dysfunction and ifnot drained can cause respiratory compromise.

Chylothorax can compress the lung resulting in shortness of breath and respiratory distress.Empyema is a rare complication due to the bacteriostatic nature of lecithin and fatty acids.Sterile chyle does not cause pleuritic pain or a fibrotic inflammatory reaction. Loss of proteinsand vitamins, more than fat, leads to metabolic and nutritional defects, immunodeficiency,coagulopathy, malnutrition and death. A prompt diagnosis and an accurate early treatmentare therefore essential. Analysis of the effusion demonstrates a triglyceride level >110 mg/dLand a lymphocyte count >90%, gram, Sudan 3 stain, chylomicrins on electrophoresis. The totalprotein concentration in the effusion is near or equal to the plasma protein concentration.

Leads to cardiopulmonary abnormalities and metabolic and immunologic

Mostly, it occurs from 2 days to 4 weeks postoperatively and varies from slight to severe formsdetermined by the volume and rate of chyle loss. Conservative treatment initially involvesreplacing the nutrients lost in the chyle and draining large chylothoraces using chest draininsertion if necessary, to ensure complete lung expansion, nil by mouth or the administrationof low fat medium chain triglycerides by mouth. Medium chain triglycerides are directlyabsorbed in to the portal system, bypassing the intestinal lymph system. This reduces the flowof chyle in the thoracic duct allowing it the opportunity to heal. [111] If the chyle leak does notstop following the use of medium chain triglycerides, then total parenteral feeding to reducethe chyle flow even further should be considered. [111]- [112] Somatostatin and octreotide haveproved to be useful in the conservative treatment of chylothorax. These agents reduce intestinalchyle production, thereby reducing the volume flowing through the injured thoracic duct.[113]- [115]

Chemical pleurodesis with TALC is an alternative option in the majority of patients that aretoo unwell for surgical closure of the chyle leak. A cannulation and embolisation technique


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prospectively to treat chylothorax was curative in patients’ with demonstratable duct leakage[115] however reproducibility and success have varied in different centres. Surgical therapy[115] is recommended in cases where despite conservative management the patient drainsmore than 1.5 l/day in an adult or >100 ml/kg body weight per day in a child, leaks chyle at arate of >1 l/day for5 days or has persistent chyle flow for more than 2 weeks. Surgery is alsorecommended if there has been a rapid decline in nutritional status despite conservativemanagement. Thoracic duct ligation can be performed during thoracotomy or by thoraco‐scopic intervention. [116], [117] The main problem is identifying the chyle leak. Ligation of thethoracic duct is successful in 90% of patients when performed just above the right hemi-diaphragm. [118] Ligating here, also has the advantage of halting flow from any unidentifiedaccessory ducts. Collateral circulation redirects the chyle around the ligation point ensuringthat the chyle still completes its journey to the circulation. In cases of loculated or complicatedchylothorax pleural decortication with pleurodesis may be performed. [115]

5.12. Prolonged air leak

One of the common problems after thoracic surgery is prolonged postoperative air leak. Notall patients have an air leak after pulmonary resection. However, many patients having alobectomy, segmentectomy, or a complicated wedge resection will leave the operating roomwith a leak

The vast majority of postoperative air leaks, however, are alveolar air leaks, and thereforeinitial management should be aimed at treating this entity. The management of bronchopleuralfistulas is substantially different than that of alveolar air leaks, often requiring early surgicalintervention. [119]

Air leaks that persist beyond a certain point may prolong the hospital length of stay. TheSociety of Thoracic Surgeons database mentions air leaks are those which are typically presentwhen the patient could otherwise be discharged were it not for a continued air leak. The STSThoracic Surgery Database defined prolonged air leak as lasting >5 days. Prolonged air leakmay be associated with an increased complication rate and certainly may increase length ofstay. Okereke et al. [120] found complications in up to 30% for patients with any air leak butonly 18% in patients without, but this may have been a marker of extent of surgery or disease.Varela and colleagues [121] found that air leak lasting at least 5 days was associated withgreater pulmonary morbidity, such as atelectasis, pneumonia, and empyema. They also foundthat the length of stay was extended by 6 days. Most leaks will stop within 2 to 3 weeks

By far the most common treatment of airleaks is watchful waiting with continuous drain‐age through a tube thoracostomy. More than 90% of air leaks seemed to stop within sev‐eral weeks after operation with this form of management alone, with only raredevelopment of an empyema. [119]A valved, outpatient system, such as a Heimlich, canonly be considered in patients who have no more than a small, stable, asymptomaticpneumothorax on water seal. [119]

Blood patch or chemical pleurodesis may be considered as the next step. Experience with thesetechniques is variable. The instillation of sclerosing materials into the pleural space through


the thoracostomy tube promotes symphysis of visceral and parietal pleura and may produceleak closure. Given the low rate of infection reported in published series, it remains unclearwhether antibiotics should routinely be used. [119]

Autologous blood patch is another nonsurgical option to treat PAL after the operation orspontaneous pneumothorax [122]- [127]. To summarize, blood-patch pleurodesis involves theinstillation of autologous blood into the pleural space through a chest catheter. It is simple,relatively painless, and often effective, but some information suggests that blood-patchpleurodesis may also carry an increased risk of intrathoracic infection. Although there are sixarticles on this subject, it is difficult to draw definitive conclusions due to the variable studysizes (from 2 patients to 32 patients), quantity of blood injected (50 to 150 mL), and endpointdefinitions.

Pneumoperitoneum instilled through a transabdominal catheter has been reported to beeffective in some cases [128], [129]. Surgical options to accomplish pleural symphysis or controlthe source of an alveolar air leak, or both, include video-assisted thoracic surgery (VATS) withparenchymal stapling, VATS with chemical pleurodesis, VATS with pleural abrasion [130],[131], VATS with application of topical sealants [132], [133], and the less well-supported useof VATS with laser sealing of the site of leak [134]. Omental or muscle flaps placed at re-thoracotomy can also be used successfully to obliterate the pleural space in patients withincomplete lung expansion and residual air leaks [135].

6. Injuries to surrounding structures

Injuries can happen to the oesophagus, phrenic nerve, recurrent laryngeal nerve, durallacerations and spinal cord injury and peripheral embolisation of tumour.

6.1. Injury to the phrenic nerve

Thoracic surgical procedures can produce phrenic nerve injury. It happens when thereare adhesions or in redo surgeries. Surgeries like anterior mediastinal tumor excision, re‐section of superior sulcus tumours, repair of thoracic outlet syndrome, or right-sided me‐diastinal lymph node dissection could all cause phrenic nerve injury. Such injuries maybe temporary or permanent. Presenting features are shortness of breath on exertion andimpaired exercise tolerance [136]. If patients are on a ventilator then there may be diffi‐culty in weaning of ventilator. X-ray shows elevation of the affected hemi diaphragm.This is confirmed by ultrasound or fluoroscopy, which is the diagnostic study of choicein evaluation of these injuries. The best method of management of unilateral palsy is dia‐phragmatic plication [136].

6.2. Injury to the recurrent laryngeal nerve

Injury to the recurrent laryngeal nerve generally present in the postoperative phase witha weak hoarse and whispery voice. They nay describe a voice, which gets weaker as the


73

day progresses, which may cause aspiration or impaired physiotherapy due to inabilityto cough effectively. A laryngoscopy is done to confirm the diagnosis and adduction ofthe affected vocal cord or sluggish motion will be absent. Treatment depends on whetherthe injury is temporary or permanent. A fibre optic evaluation is necessary to test swal‐lowing and sensation. To assist with pulmonary physiotherapy and decrease the risk ofaspiration, medialization laryngoplasty may be suggested [136]. This can be done as anoffice procedure with the aid of autologous fat, Gel foam, collagen, or polytetrafluoro‐ethylene. [136]

7. Infections

Infectious complications after pulmonary surgery include operative wound infection, em‐pyema, and nosocomial pneumonia. Antibiotic prophylaxis should therefore be guidedagainst these three entities. The incidence varies from 5% to 24.4%. They are responsiblefor increased hospital mortality to up to 19% as well as increased costs and length of hos‐pital stay. In one study 53.6% of the germs identified were gram-negative bacteria, 39.3%gram-positive bacteria, and 7.1% were fungi [137]. These infections should be aggressive‐ly treated with appropriate antibiotics after culture. Chest physiotherapy, pain control,bronchodilators, and early ambulation should be done for all patients but regardless ofthese pneumonia develops. Postoperative atelectasis after pulmonary surgery should beaggressively managed before it deteriorates into pneumonia. Our policy is to give Ticar‐cillin Sodium and Potassium Clavulanate 3.1 g four times a day in divided doses till apositive culture is obtained.

The incidence of empyema is dropping but could happen if there is prolonged air leak.Generally they are managed with antibiotics but may necessitate thoracotomy and wash out.

Other complications include pulmonary embolism, deep venous thrombosis, renal failure,strokes, major gastrointestinal bleed and late empyema. These complications should berecognised very early and aggressive management should be instituted if they are to be tackledsuccessfully.

Thus postoperative care and management of postoperative complications is a team approachand good preoperative and intraoperative measures minimize the incidence of postoperativecomplications and early recognition and treatment is essential for successful outcomes.

Author details

Anand Iyer and Sumit Yadav

Department of Cardiothoracic surgery, Townsville Hospital, Queensland, Australia


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